EHR REPLACEMENTFINDING THE BEST CHOICE FOR YOUR PRACTICE, THE SECOND TIME AROUND.5

Jay Alexander, MD, FACCNorthShore University HealthSystem

The tides have shifted quickly in the EHR marketplace. As adoption surpassed 50%, dissatisfaction began rising sharply. Today, more than half of EHR systems sold are replacement systems.

BACKGROUND NorthShore Cardiologists, a 12-physician practice with four locations in north Chicago, was among the

early adopters of electronic medical record technology in 2004. Pleased with the performance of the

practice management system they’d been using, the practice made the assumption that an electronic

health record (EHR) from the same vendor would be a logical choice. Two years and more than $400,000

later, only three physicians were actually using the system, and nobody was happy.

The practice made the difficult decision to abandon its original EHR and went in search of a second,

but better choice. Armed with insight from an unsuccessful implementation, the practice knew what to

look for and what to avoid. They found what they considered an ideal system, and within three months,

had all twelve cardiologists and 60 employees up, running and productive.

In 2010, the practice faced another difficult decision — giving up its EHR to become part of a large

hospital-based system. Dr. Alexander admits that losing the EHR they’d worked so hard to find weighed

mightily when considering acquisition. In the end, the practice sold and migrated to a new system,

but not without remorse. Dr. Alexander still champions the system he lost, and in this case study,

shares “the good, the bad and the ugly” of EHR replacement.

the growing case for EHR replacement

PRACTICES SHOPPING FOR AN EHR WHO ARE NOT FIRST-TIME BUYERS5

VERY DISSATISIFIED5

EHR SATISFACTION 5

( AMERICANEHR PARTNERS ) ( AMERICANEHR PARTNERS ) ( KLAS RESEARCH )

TAKING THE LONG VIEWLike most practices, NorthShore was originally interested in the increased efficiency and productivity promised by electronic medical records. But the partners were also looking ahead to the long-term health of the practice.

We saw that the writing was on the wall with the advent of pay for performance programs, and recognized the value of EHR going forward. Not only could we automate the reporting processes and ensure we were following best practices, but we could also use information generated from an EHR to prove to health plans that we were doing what was medically appropriate,” Alexander recalls. “While an EHR can serve simply as an electronic record database, there is tremendous value in using the rich clinical information in that database to improve care as well as practice performance.”

NorthShore set out to find a system to position the practice for inevitable changes in healthcare delivery, and improve the practice’s negotiating position with payor organizations. The selection process began in a familiar place with the vendor whose practice management system they were already using.

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OUR FIRST MISTAKE”

As they eventually discovered, this was their first mistake.

North Shore selected its first EHR based on the fact they were reasonably happy with the vendor’s practice management system. They assumed that the vendor’s EHR system would perform in a similar fashion and, since they were from the same company, both systems would integrate seamlessly. “We tested this hypothesis and learned the hard way that this approach can have serious flaws. In short, a reasonably good PM systems does not equal a reasonably good EHR system,” says Alexander.

Alexander and his colleagues found the system to be inflexible and unadaptable, forcing all users to conform to a single workflow, using a single template. “While one can argue that this is the right way to do things, most physicians are not big fans of conformity. There needs to be an appropriate balance, and our system did not provide for that,” Alexander says.

The practice requested a custom solution, but the response was slow and the process expensive.

INFLEXIBLE SYSTEM, INFLEXIBLE VENDOR

Our EHR vendor turned out to be as inflexible as their software,” Alexander says. “They were slow to respond to our requests for changes and improvements, always promising to make the modification on the next upgrade, which could mean waiting as long as a year.”

That was our second misconception — that a larger company would be a safer choice. But bigger does not mean better. The larger the company, the larger the chances they will be slow, unresponsive, rigid and unable to adjust to meet customer needs,” Alexander says.

THE FINAL STRAW

After two years of struggle, NorthShore had spent more than $400,000 on an EHR that only three physicians — the most tech-savvy of the group — were even using, and nobody was happy. The final straw came when the EHR vendor informed the practice that, in order to get the system to do what the users really wanted, it would require an additional $80,000 investment.

Our intent when we added an EHR was to be an early adopter — to be the first on our particular block to reap the benefits of electronic health records. While implementing an EHR was the right thing to do, we made a critical mistake with the system we selected. We decided to stop throwing good money after bad,” Alexander says.

After nearly three years and $500,000, NorthShore decided to abandon its EHR and set about looking for a replacement.

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learning from experience:

WHAT TO AVOID The difference between first-time EHR buyers and those searching for a replacement system can

be summed up in a single word: experience. Replacement buyers know what they are looking for

(and likely didn’t get with their first choice). Equally important, they have a clear-cut list of what they

want to avoid.

Dr. Alexander counsels replacement buyers that the first thing to avoid is assumptions.

The first time out, we took what appeared to be the path of least resistance and ended up learning

some tough lessons,” Alexander says. Among them:

3 3 Do not assume that your EMR and PM should come from the same company.3 Do not assume that bigger is better.3 Do not assume that the more you spend, the more you get.

a simple goal: cognitive, not clerical

Practices implementing EHR are quick to cite increasing productivity and efficiency as primary goals,

often leaving the most important goal — treating the patient — unaddressed. A good system should effectively

improve all of those things.

Dr. Alexander explains, “Encounter documentation should be relatively simple, so you can focus on cognitive

thinking rather than clerical work.” Alexander does not document everything when he’s with the patient,

opting to complete his encounter notes later. “My system helps me balance what I do when, so I don’t intrude

too much on service to my patients, or to my home life.”

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WARNING SIGNS

If an EHR system your practice is evaluating reveals any of the following, take it as a warning sign:

3 Systems that require dramatic changes to your workflow to fit the EHR application.

While a good EHR company can provide some valuable consultation on workflow improvements,

you should not be forced to make wholesale changes to the way you practice medicine.

3 Systems that impede patient interaction.

Beware of any system that requires you to spend more time interacting with the computer than

with your patients.

3 Systems that suggest reduced patient volume is an unavoidable side effect

of the implementation process.

If the EHR is slowing you down significantly, your revenues and productivity will suffer. The right

system, along with pre-implementation training and support, are effective prevention.

3 Systems that require big up-front investment.

Alexander sums it up simply: “If the system comes with a hefty up-front investment in hardware,

database licenses and IT support, keep looking.”

3 Style over substance.

Flashy graphics and user interfaces do not get the job done. Just as you cannot judge a book by

its cover, you need to look under the hood and evaluate what the system can and cannot do.

WHAT TO LOOK FORIn NorthShore’s case, there were two must-haves for the replacement EHR: it had to be affordable, and it had to be flexible. “We were not in a position to repeat our original investment, so affordability was extremely important. And, given our experience with an inflexible vendor and EHR system, we wanted a company that was agile and responsive, with a system that could be modified easily, rapidly and affordably,” Alexander says.

Look for systems and suppliers that are:

3 responsive. Questions, concerns and required modifications should be addressed on your schedule — not theirs.3 nimble. Change is constant. The system should be able to evolve and adapt.3 collaborative. Think partnership, not purchase. Look for a relationship where your input is invited and welcomed.

WORDS TO THE WISE

One size does not fit all. Look for an EHR that can be configured for your practice

and the preferences of your individual physicians. Insist on the flexibility to document

encounters using the methodology best for the practice and the patient, and adaptable

to a wide variety of clinician attitudes and comfort levels with technology.

Opt for a web-based system. Web-based systems are generally more affordable

(no additional hardware to buy and support), and offer the added benefit of anywhere,

anytime access to patient records. Make sure the system is natively web-based,

not reverse-engineered to work on the internet.

Choose a system that is ONC-ATCB certified. While certification alone is no guar-

antee the system will be right for your practice, this should be a minimum requirement.

Be insistent about interoperability. As technology options continue to grow,

so too does the importance of standards-based interoperability. Look for a system built

for data exchange — with other providers and systems, patient portals, registries and

the patients themselves.

Equip yourself for quality initiatives. PQRS and other quality initiatives are here to

stay. Choose an EHR that can help you automate program requirements.

Go at your own speed. The best EHR systems allow your practice to implement

in modular increments. Some practices start with a single doctor, or go practice-wide

with basic functionality to give users a chance to build their skills and confidence

before adding modules.

Alexander advises, “Make certain you test drive the EHR systems you are

considering. Get a thorough demo and make sure you spend time interacting with

the system yourself.”

Our EHR company describes its approach as minimally invasive. Their approach

minimizes practice upheaval, and the system is accessible, interoperable, flexible and

affordable,” he continues. “We experienced minimal invasiveness to our workflow —

a welcome change from our previous EHR.”

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MEASURABLEOUTCOMESThe success of NorthShore’s replacement EHR initiative started with user adoption. In less than three months’ time, the practice had brought 12 cardiologists and 60 employees online. Alexander says, “Even those who were most resistant to moving away from paper charts were now regularly logging in to view patient charts online and to experiment with functionality in our new EHR system.”

He continues, “I am living proof that there is life after a bad EHR choice. Our practice tried to get ahead of the curve by adopting early. As it turns out, we chose our first EHR badly. The good news for us is we were able to recover, albeit after wasting a significant sum on our first EHR.The good news for you is that we are willing to share our experiences so that you can avoid making the same costly mistakes.”

do your due diligence

Sites and other sources of EMR information

> Colleagues — peers can be an invaluable source of insight on actual day-to-day use and performance

of EHR systems in your specialty. Ask for the positives and the negatives.

> Associations — check your specialty association website recommendations and reviews

> HIEs/RECs — look to state and local agencies for information

> Vendor neutral websites — check websites such as HealthIT.gov and KLASresearch.com

> Product demos — request a demonstration of the system that focuses on the functionality important

to your practice

LOOKING BACK…DR. ALEXANDER ON SELECTING, USING AND LONGING FOR WEBCHART

With the decision made to abandon our old EHR, we set about looking for a replacement. Our first time out, we took what appeared to be the path of least resistance and purchased the EHR that our PM vendor was offering. The second time around, we spent quite a bit of time talking to other cardiologists to learn about their experiences. We looked at a number of systems from several vendors, including some of the largest EHR companies, but in the end, we took the advice of a trusted colleague and got serious about WebChart from MIE.

This particular company and this EHR had several things going for it. First the system was far more affordable — up-front and over the long haul. The system is web-based, so we did not have to invest in servers and other hardware, and we did not have to pay exorbitant database licensing fees. The company minimizes the initial costs, and we paid a monthly fee based on the number of physicians. While some people are concerned that the fee structure would mean paying more long term, we calculated that we would save the costs associated with hardware upgrades, licensing fees, IT support and other expenses that are borne by the company.

The SaaS model creates a second major benefit — we could access our patient records virtually anytime, anywhere, as long as we had an internet connection. We have four offices and spend time in six different hospitals. I could get on any computer — including at home when I get that late night call — log in and see my patients’ records — with no special software.

The initial investment with WebChart was focused on configuration — they actually tailor the software for your practice. This was the third significant benefit for us — flexibility. We discovered that the right EHR does not force you to make major changes in practice workflow. Instead, our WebChart system was modified to fit the workflow we already had in place. The company suggested some best practices to help us improve efficiency and productivity, but they were also happy to configure their application to fit our preferences.

I want to see the information I want to see, where I want to see it, the way I want to see it. And if I decide I want to move things around, WebChart let me do that.

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Jay's "top five" for WebChart

1. Affordable — web-based means no hardware to buy and maintain2. Accessible — 24/7/365 access to patient charts from any internet-enabled device3. Flexible — adapts to your practice workflow and user preferences4. Functionally robust — integrates high-productivity tools on a single platform5. Responsive — requests are addressed rapidly, input is always welcomed

WebChart EHR is ONC-ATCB certified for meaningful use and interoperable with PM/billing systems, other applications, patient portals, devices and HIEs.

Working with WebChart, we were able to set up point-and-click templates that fit our approach to documentation. Our ability to make changes on the fly was incredibly valuable. I could ask for changes to our template, and they happened very rapidly.

The system functionality is really robust. The PQRS module in WebChart enabled us to easily and automatically report to CMS and collect our bonuses. The built-in document management functionality allowed us to deal with paper both inside and outside the practice, making critical documents a part of our online record. This included the capability of printing out bar-coded encounter forms for physicians who still wanted to chart on paper. After the patient visit, these forms could be fed into a high-speed scanner and the bar code auto-indexes an image of the forms in the electronic record. While I prefer to do everything electronically, this was a comfortable transition step for those who weren’t quite ready to let go of paper.

WebChart also let us add PACS functionality, enabling us to view and manage radiology studies, echocardiograms and other diagnostic images.

After working with much larger EHR companies that possess the agility of an oil tanker, collaborating with an agile and responsive organization was a breath of fresh air. I wish I could say this was the happy ending to my story, but it’s not.

Our practice was acquired by a local hospital system, and we have now migrated to our third EHR. During negotiations, we fought hard to retain WebChart for our practice, but the hospital insisted on a single, system-wide EHR solution. My partners and I debated whether to remain independent so we could remain on WebChart, but there were a number of reasons why acquisition made sense. While I understand the need for an enterprise-wide health IT solution, I still log in to my WebChart solution every day, remembering everything I wish I still had.

If you are a first-time EHR buyer, I urge you to learn from our costly, but avoidable mistakes. When we decided to get rid of our first EHR and purchase a second solution, I was not the most popular individual in the office. While I ran the practice as a benevolent dictatorship, I did not enjoy wearing a target to work each day. While there was no question of whether to purchase a new EHR, we were determined to get our second choice right.

If your practice is independent and you have an EHR solution you are unhappy with, I am living proof that the migration from an underperforming system to a second but better choice is worth the effort. The difference between our first EHR and our second choice was the difference between night and day.”

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THE WEBCHART EHRREPLACEMENT PROGRAMRanked #2 by KLAS1, WebChart is a preferred choice for EHR replacement for three simple reasons:

FLEXIBILITY — WebChart adapts to your practice workflow, helping your clinicians stay cognitive, not clerical.

Screens can be configured for each user to ensure peak productivity. Documentation options include point

and click templates, dictation and document scanning.

SUPPORT — WebChart support starts even before your system goes live. An experienced implementation

specialist will work directly with your practice to make sure users have the hands-on training they need

to use WebChart with efficiency and confidence. Help desk assistance is available whenever you need it

from our US-based support center.

TOTAL COST OF OWNERSHIP — Replacing an EHR can feel like adding insult to injury — absorbing the

cost of the failed system and then being asked to start over again, financially and operationally. WebChart

offers an affordable option — a web-based system that requires no additional hardware or software to

buy and maintain. Plus, our minimally invasive approach minimizes disruption, protecting productivity

throughout the transition to WebChart and beyond. Hosting, maintenance and upgrades are all included

in an affordable monthly fee.

Replacing an EHR isn’t a decision made lightly. Whatever brought your practice to this point, we suggest no better

time to thoroughly assess what you’re looking for in a long-term solution. Based on its inherent flexibility, the WebChart

system can be configured even down to the individual user level, with different functionality and views as appropriate

for your staff. Working collaboratively throughout the assessment process, we’ll help you set priorities that will simplify

conversion and minimize disruption.

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the WebChart replacement process

assess

4 What went wrong?4 Round two: must have/avoid4 MU status4 Terms w/current vendor4 Data conversion requirements4 Workflow assessment4 Gap analysis4 Timing

4 Configuration

4 MU consulting

4 Training

4 Data conversion

4 Parallel ops/testing

4 Refine

Cutover

4 WebChart configuration4 Implementation plan4 Data conversion4 Parallel operation, testing and cutover4 Training4 MU requirements

plan implement and transition

1 “Saas EMR: Is it right for you?” May 2012 ©2012 KLAS Enterprises, LLC. All rights reserved. www.KLASresearch.com

With WebChart, you’re getting more than an EHR. You’re adding a partner. That means you receive ongoing benefits — including system maintenance and upgrades, access to knowledge and expertise, and a team of professionals on the forefront of health information technology.

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TAKE DR. ALEXANDER'S ADVICE: TEST DRIVE WEBCHART WITH NO OBLIGATION Try WebChart free in your practice for 30 days and experience the benefits first-hand. Your trial includes training and implementation support, all at no obligation.

Call for details today: 1-888-498-3484, option 2 — or visit www.webchartnow.com.

6302 Constitution Drive / Fort Wayne, IN 46804p: 260-459-6270 / f: 260-459-6271info@mieweb.comwebchartnow.com

the minimally invasive EHR®

ABOUT DR. ALEXANDER

Jay Alexander, MD, FACC, FASNC, is a cardiologist at NorthShore University HealthSystem in suburban Chicago,

specializing in clinical cardiology, cardiac pacing and noninvasive cardiac imaging. He also serves as the medical

director at iRhythm Technologies, a medical device manufacturer focusing in cardiac rhythm monitoring.

Dr. Alexander is a graduate of the Loyola University Chicago Stritch School of Medicine, and Indiana University

where he earned an undergraduate degree in biology. A bit of a geek, he is an early adopter with a keen appreciation

of technology. He misses his WebChart.

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